Introduction
Materials and methods
Statistical analysis
Results
Demographic characteristics | (N = 323) |
---|---|
Age1, years | 57.5 ± 15.3 |
Gender2, male (%) | 224 (69.3) |
Pre-existing disease
2
| |
Diabetes mellitus | 195 (60.4) |
Liver disease | 91(28.2) |
Renal disease | 60 (18.6) |
Heart disease | 43 (13.3) |
Peripheral vascular disease | 27 (8.4) |
Intravenous drug use | 15 (4.6) |
Clinical features
2
| |
Infected site, limbs | 276 (85.4) |
Tender | 261(80.8) |
Erythema | 252 (78.0) |
Presence of sepsis | 244 (75.5) |
Tachycardia | 152 (47.1) |
Bullae formation | 132 (40.9) |
Fever | 103 (31.9) |
Hypotension | 42 (13.0) |
Therapeutic factors and the outcomes
| |
Operation within 24 hours2 | 222 (68.7) |
Amputation2 | 83 (25.7) |
Mortality2 | 52 (16.1) |
Number of debridement1, number | 3.14 ± 2.2 |
Hospital length of stay1, days | 35.0 ± 26.1 |
Wound culture, positive (%)
| 279 (86.4) |
Blood culture, positive (%)
| 65 (20.1) |
Variable | Single etiologic agent (n= 126) | Multiple etiologic agents (n= 153) | P-value |
---|---|---|---|
Gram-positive cocci
| |||
Aerobic
| |||
Staphylococcus aureus | |||
Methicillin-susceptible S. aureus | 27 (21.4) | 15 (9.8) | 0.007* |
Methicillin-resistant S. aureus | 20 (15.9) | 34 (22.2) | 0.182 |
Coagulase-negative Staphylococcus | 2 (1.6) | 11 (7.2) | 0.042* |
Streptococcus | |||
Beta-hemolytic (Group A) | 13 (10.3) | 24 (15.7) | 0.188 |
Beta-hemolytic (Group B) | 2 (1.6) | 4 (2.6) | 0.693 |
Non-group A or B | - | 2 (0.7) | - |
S. viridans
| 2(1.6) | 36 (23.5) | <0.001* |
Enterococcus faecalis | 1(0.8) | 45 (29.4) | <0.001* |
Anaerobic
| |||
Peptostreptococcus | - | 38 (13.6) | - |
Gram-positive rods
| |||
Aerobic
| |||
Corynebacterium | - | 8 (2.9) | - |
Anaerobic
| |||
Clostridium spp. | - | 5 (1.8) | - |
Gram negative rods
| |||
Aerobic
| |||
Acinetobacter baumannii | 3 (2.4) | 20 (13.1) | 0.001* |
Aeromonas spp. | 11 (8.7) | 11 (7.2) | 0.635 |
Citrobacter spp. | 2 (1.6) | 9 (5.9) | 0.119 |
E.coli. | 2 (1.6) | 35 (22.9) | <0.001* |
Enterobacter spp. | 1 (0.8) | 19 (12.4) | <0.001* |
Klebsiella pneumoniae | 13 (10.3) | 28 (18.3) | 0.061 |
Pseudomonas aeruginosa | 3 (2.4) | 16 (10.5) | 0.008* |
Vibrio spp. | 21 (17.5) | - | - |
Eikenella corrodens | - | 4 (2.6) | - |
Klebsiella oxytoca | - | 3 (2.0) | - |
Proteus mirabillis | - | 23 (15.0) | - |
Serratia marcescens | - | 7 (4.6) | - |
Other gram negative rods | 1 (0.8) | 15 (9.2) | 0.002* |
Anaerobic
| |||
Prevotella spp. | 2 (1.6) | 10 (6.5) | 0.071 |
Bacteroides fragilis | - | 15 (9.8) | - |
Fusobacterium | - | 1 (0.7) | - |
Veillonella | - | 3 (2.0) | - |
Fungus
| - | 6 (3.9) | - |
Variable | Single etiologic agent (n= 61) | Multiple etiologic agents (n= 4) | P-value |
---|---|---|---|
Gram-positive bacteria
| |||
Aerobic
| |||
Staphylococcus aureus
| |||
Methicillin-susceptible S. aureus | 9 (14.8) | 1 (25.0) | 0.496 |
Methicillin-resistant S. aureus | 7 (11.5) | - | - |
Streptococcus
| |||
Beta-hemolytic (Group A) | 5 (8.2) | - | - |
Beta-hemolytic (Group B) | 1 (1.6) | 1 (25.0) | 0.120 |
Anaerobic
| |||
Peptostreptococcus | 1 (1.6) | 1 (25.0) | 0.120 |
Gram negative bacteria
| |||
Aerobic
| |||
Acinetobacter baumannii | 2 (3.3) | - | - |
Aeromonas spp. | 6 (9.8) | - | - |
Citrobacter spp. | 1 (1.6) | - | - |
E.coli | 3 (4.9) | 2 (50.0) | 0.027* |
Enterobacter spp. | 1 (1.6) | 1 (25.0) | 0.120 |
Klebsiella pneumoniae | 2 (3.3) | 1 (25.0) | 0.176 |
Proteus mirabillis | 1 (1.6) | - | - |
Vibrio spp. | 20 (32.8) | - | - |
Other gram negative rods | 1 (1.6) | - | - |
Anaerobic
| |||
Prevotella spp. | 1 (1.6) | - | - |
Bacteroides fragilis | - | 1 (25.0) | - |
Variable | Survival (n= 232) | Death (n= 47) | P-value |
---|---|---|---|
Gram-positive cocci
| |||
Aerobic
| |||
Staphylococcus aureus | |||
Methicillin-susceptible S. aureus | 39 (16.8) | 3 (6.4) | 0.075 |
Methicillin-resistant S. aureus | 47 (20.3) | 7 (14.9) | 0.543 |
Coagulase-negative Staphylococcus | 12 (5.2) | 1 (2.1) | 0.703 |
Streptococcus | |||
Beta-hemolytic (Group A) | 32 (13.8) | 5 (10.6) | 0.645 |
Beta-hemolytic (Group B) | 4 (1.7) | 2 (4.3) | 0.267 |
Non-group A or B | |||
S. viridans
| 33 (14.2) | 5 (10.6) | 0.644 |
Enterococcus faecalis | 37 (15.9) | 9 (19.1) | 0.666 |
Anaerobic
| |||
Peptostreptococcus | 30 (12.9) | 8 (17.0) | 0.485 |
Gram-positive rods
| |||
Aerobic
| |||
Corynebacterium | 7 (3.0) | 1 (2.1) | 1.000 |
Anaerobic
| |||
Clostridium spp. | 2 (0.9) | 3 (6.4) | 0.035* |
Gram negative rods
| |||
Aerobic
| |||
Acinetobacter baumannii | 20 (8.6) | 3 (6.4) | 0.776 |
Aeromonas spp. | 18 (7.8) | 4 (8.5) | 0.773 |
Citrobacter spp. | 10 (4.3) | 1 (2.1) | 0.697 |
E.coli. | 29 (12.5) | 8 (17.0) | 0.478 |
Enterobacter spp. | 15 (6.5) | 5 (10.6) | 0.349 |
Klebsiella pneumoniae | 36 (15.5) | 5 (10.6) | 0.501 |
Pseudomonas aeruginosa | 16 (6.9) | 3 (6.4) | 1.000 |
Vibrio spp. | 11 (4.7) | 11 (23.4) | <.001* |
Eikenella corrodens | 4 (1.7) | - | - |
Klebsiella oxytoca | 3 (1.3) | - | - |
Proteus mirabillis | 23 (9.9) | - | - |
Serratia marcescens | 7 (3.0) | - | - |
Other gram negative rods | 12 (5.2) | 3 (6.4) | 0.724 |
Anaerobic
| |||
Prevotella spp. | 12 (5.2) | - | - |
Bacteroides fragilis | 11 (4.7) | 4 (8.5) | 0.292 |
Fusobacterium | 1 (0.4) | - | - |
Veillonella | 2 (0.9) | 1 (2.1) | 0.426 |
Fungus
|
5 (2.2)
| 1 (2.1) |
1.000
|
Variable | Survival (n= 41) | Death (n= 24) | P-value |
---|---|---|---|
Gram-positive bacteria
| |||
Aerobic
| |||
Staphylococcus aureus
| |||
Methicillin-susceptible S. aureus | 10 (24.4) | - | - |
Methicillin-resistant S. aureus | 5 (12.2) | 2 (8.3) | 1.000 |
Streptococcus
| |||
Beta-hemolytic (Group A) | 2 (4.9) | 3 (12.5) | 0.350 |
Beta-hemolytic (Group B) | 1 (2.4) | 1 (4.2) | 1.000 |
Anaerobic
| |||
Peptostreptococcus | 2 (4.9) | - | - |
Gram negative bacteria
| |||
Aerobic
| |||
Acinetobacter baumannii | - | 2 (8.3) | - |
Aeromonas spp. | 3 (7.3) | 3 (12.5) | 0.662 |
Citrobacter spp. | 1 (2.4) | ||
E.coli | 3 (7.3) | 2 (8.3) | 1.000 |
Enterobacter spp. | 1 (2.4) | 1 (4.2) | 1.000 |
Klebsiella pneumoniae | 3 (7.3) | ||
Proteus mirabillis | 1 (4.2) | ||
Vibrio spp. | 11 (26.8) | 9 (37.5) | 0.412 |
Other gram negative rods | 1 (2.4) | - | - |
Anaerobic
| |||
Prevotella spp. | 1 (2.4) | - | - |
Bacteroides fragilis | - | 1 (4.2) | - |
Variables | Survival (n= 271) | Death (n= 52) | OR (95% CI.)3 | P-value4 |
---|---|---|---|---|
Age
1
, years
| 57.4 ± 15.5 | 58.4 ± 14.2 | 1.00 (0.98 to 1.02) | 0.607 |
Gender
2
, males (%)
| 192 (70.8) | 32 (61.5) | 1.24 (0.64 to 2.41) | 0.525 |
Pre-existing disease
2
| ||||
Fever, n (%) | 85 (31.4) | 18 (34.6) | 1.16 (0.62 to 2.17) | 0.645 |
Tachycardia | 126 (46.5) | 26 (50.0) | 1.05 (0.58 to 1.90) | 0.872 |
Hypotension | 30 (11.1) | 12 (23.1) | 7.07 (3.48 to 14.37) | <.001* |
Diabetes mellitus | 167 (61.6) | 28 (53.8) | 1.06 (0.58 to 1.95) | 0.851 |
Heart disease | 37 (13.7) | 6 (11.5) | 3.52 (1.72 to 7.20) | 0.001* |
Peripheral vascular disease | 23 (8.5) | 4 (7.7) | 0.39 (0.09 to 1.71) | 0.214 |
Renal disease | 49 (18.1) | 11 (21.2) | 1.59 (0.79 to 3.21) | 0.196 |
Liver disease | 74 (27.3) | 17 (32.7) | 2.37 (1.28 to 4.37) | 0.006* |
Intravenous drug use | 14 (5.2) | 1 (1.9) | 0.36 (0.05 to 2.80) | 0.329 |
Clinical features
2
| ||||
Affected site (limbs) | 228 (84.1) | 48 (92.3) | 1.11 (0.47 to 2.64) | 0.808 |
Bullae formation | 109 (40.2) | 23 (44.2) | 1.18 (0.65 to 2.15) | 0.590 |
Operation within 24 hours | 187 (69.0) | 35 (67.3) | 0.68 (0.35 to 1.26) | 0.224 |
Amputation | 70 (25.8) | 13 (25.0) | 1.86 (0.99 to 3.50) | 0.053 |
Debridement > = 3 times | 157 (57.9) | 11 (21.2) | 0.19 (0.10 to 0.39) | <.001* |
Multiple Etiologic agent in Wound culture
2
, n (%)
| 129 (47.6) | 24 (46.2) | 0.94 (0.52 to 1.71) | 0.848 |
Gram positive organism in wound culture
2
| ||||
Streptococcus group A | 32 (11.8) | 5 (9.6) | 0.79 (0.29 to 2.14) | 0.650 |
Streptococcus group B | 4 (1.5) | 2 (3.8) | 2.67 (0.48 to 14.97) | 0.264 |
Methicillin-susceptible
S. aureus
| 39 (14.4) | 3 (5.8) | 0.36 (0.11 to 1.23) | 0.103 |
Methicillin-resistant S. aureus | 47 (17.3) | 7 (13.5) | 0.74 (0.31 to 1.74) | 0.493 |
Gram negative organism in wound culture
2
| ||||
Acinetobacter baumannii | 20 (7.4) | 3 (5.8) | 0.77 (0.22 to 2.69) | 0.680 |
Aeromonas spp. | 18 (6.6) | 4 (7.7) | 1.17 (0.38 to 3.61) | 0.783 |
E.coli | 29 (10.7) | 8 (15.4) | 1.52 (0.65 to 3.54) | 0.334 |
K.pneumoniae | 36 (13.3) | 5 (9.6) | 0.69 (0.26 to 1.86) | 0.469 |
Proteus mirrabilis | 23 (8.5) | 0 (0) | - | - |
Pseudomonas spp. | 16 (5.9) | 3 (5.8) | 0.98 (0.27 to 3.48) | 0.970 |
Vibrio spp. | 11 (4.1) | 11 (21.2) | 6.37 (2.58 to 15.57) | <.001* |
Fungus in wound culture
2
| 6 (2.2) | 1 (1.9) | 6.34 (2.58 to 15.57) | <.001* |
Multiple Etiologic agent in blood culture
2
, n (%)
| 3 (1.1) | 1 (1.9) | 1.75 (0.18 to 17.17) | 0.630 |
Gram positive organism in blood culture
2
| ||||
Streptococcus group A | 2 (0.7) | 3 (5.8) | 8.24 (1.34 to 50.56) | 0.023* |
Streptococcus group B | 1 (0.4) | 1 (1.9) | 5.29 (0.33 to 86.01) | 0.241 |
Methicillin-susceptible
S. aureus
| 10 (3.7) | 0 (0) | - | - |
Methicillin-resistant S. aureus | 5 (1.8) | 2 (3.8) | 2.13 (0.40 to 11.27) | 0.375 |
Gram negative organism in blood culture
2
| ||||
Acinetobacter baumannii | 0 (0) | 2 (3.8) | - | - |
Aeromonas spp. | 3 (1.1) | 3 (5.8) | 5.47 (1.07 to 27.89) | 0.041* |
E.coli | 3 (1.1) | 2 (3.8) | 3.57 (0.58 to 21.93) | 0.169 |
Proteus mirrabilis | 0 (0) | 1 (1.9) | - | - |
Vibrio spp. | 11 (4.1) | 9 (17.3) | 4.95 (1.94 to 12.64) | 0.001* |
Variables | OR (95% CI)1 | P-value2 |
---|---|---|
Age, years
| 0.99 (0.97 to 1.02) | 0.607 |
Gender, males (%)
| 1.16 (0.50 to 2.67) | 0.731 |
Pre-existing disease
| ||
Hypotension | 5.68 (2.21 to 14.59) | <0.001* |
Heart disease | 2.89 (1.09 to 7.62) | 0.033* |
Liver disease | 2.54 (1.10 to 5.87) | 0.029* |
Clinical features
| ||
Operation within 24 hours | 0.59 (0.27 to 1.29) | 0.182 |
Debridement > = 3 times | 0.19 (0.08 to 0.43) | <.001* |
Gram negative organism in wound culture
| ||
Vibrio spp. | 5.60 (1.82 to 17.25) | 0.003* |
Fungus in wound culture
| 0.52 (0.04 to 7.54) | 0.632 |
Gram positive organism in blood culture
| ||
Streptococcus group A | 15.93 (1.95 to 130.34) | 0.010* |
Gram negative organism in blood culture
| ||
Aeromonas spp. | 3.50 (0.46 to 26.76) | 0.227 |
Vibrio spp. | 1.19 (0.29 to 4.92) | 0.806 |
Variables | Survival (n= 271) | Death (n= 52) | OR (95% CI.)3, | P-value4 |
---|---|---|---|---|
Positive blood stream infection
| 48 (17.7) | 17 (32.7) | 2.26 (1.17 to 4.36) | 0.015 |
Wound culture positive
| 235 (86.7) | 44 (84.6) | 0.84 (0.37 to 1.93) | 0.686 |
Discussion
Conclusions
Key messages
-
NF is caused by a number of different pathogens.
-
Hypotension, heart disease and liver disease were associated with higher mortality in NF patients.
-
Presence of Vibrio spp in wound cultures, and Streptococcus Group A in blood cultures were associated with a high risk of mortality.
-
Patients with positive blood stream infections had a 2.26-fold higher incidence of death, while there was no significant association between positive wound cultures and mortality.
-
Debridement > = 3 times had a lower risk of mortality.